Frederick W Hickling

The epidemiology of schizophrenia and other common mental health disorders in the English-speaking Caribbean

OBJECTIVE To report on the epidemiology of schizophrenia and other common mental health disorders in the English-speaking Caribbean. METHODS The MEDLINE, MEDCARIB and West Indiana electronic databases were searched with the phrases Caribbean AND psychiatry OR mental OR suicide, and items with specific reference to epidemiology were culled and reviewed. RESULTS The age-corrected incidence rate for schizophrenia per 10,000 is 2.09 in Jamaica, 2.2 per 1000 in Trinidad, and 2.92 in Barbados. These rates are lower than the incidence rates reported for white British people, and significantly lower that the 6- to 18-fold higher risk ratio incidence reported for African Caribbeans living in Britain. A comparative diagnostic study carried out in the United Kingdom (UK) suggests that misdiagnosis plays a significant role in this difference. Relatively low incidence figures for affective disorders, anxiety states, suicide and attempted suicide have been reported for Jamaica, Trinidad, and Barbados. DISCUSSION Most published epidemiological studies of Caribbean populations center on schizophrenia, because of the startling findings of a large increase in risk ratios for African Caribbean people living in England compared to the white native British people. The etiological evidence is shifting toward factors of racism and social alienation experienced by black people in the UK, and to misdiagnosis by white British psychiatrists. Studies of the role of colonial enslavement and social engineering raise the etiological possibility of a role for social and structural community organization in the genesis of schizophrenia. The Caribbean thus represents a rich crucible for research in the epidemiology and etiology of mental health disorders.

“Mad, Sick, Head Nuh Good”: Mental Illness Stigma in Jamaican Communities:

Stigma may be an important factor in mental health service seeking and utilization. However, little work on stigma has been conducted in developing nations in the Caribbean, including Jamaica. We explored mental illness stigma in Jamaica by conducting focus groups with 16 community samples. Four overarching conceptual themes are discussed: (1) community members’ definitions of stigma; (2) emotional responses towards those with mental illness, such as fear and love; (3) behavioral responses towards those with mental illness, including avoidance and cautious approach; and (4) perceptions of and beliefs about mental illness, including a distinction between “madness” and “mental illness.”

Deinstitutionalization and attitudes toward mental illness in Jamaica: a qualitative study

OBJECTIVE To consider whether or not deinstitutionalization and the integration of community mental health care with primary health care services have reduced stigma toward mental illness in Jamaica. METHODS A qualitative study of 20 focus groups, with a total of 159 participants grouped by shared sociodemographic traits. Results were analyzed using ATLAS.ti software. RESULTS Participant narratives showed that stigma had transitioned from negative to positive, from avoidance and fear of violent behavior during the period of deinstitutionalization to feelings of compassion and kindness as community mental health services were integrated with Jamaicas primary health care system. The Bellevue Mental Hospital and homelessness were identified as major causes of stigma. CONCLUSIONS Attitudes toward the mentally ill have improved and stigma has decreased since the increase of community involvement with the mentally ill. This reduction in stigma seems to be a result of the rigorous deinstitutionalization process and the development of a robust community mental health service in Jamaica.

Internalizing stigma associated with mental illness: findings from a general population survey in Jamaica

OBJECTIVES The culture of stigma associated with mental illness is particularly intense when persons who are normally victims of that stigmatization (mentally ill persons and their family members) themselves act negatively toward others whom they associate with mental illness. We attempt to determine the extent of this internalization and assimilation of stigmatizing attitudes, cognitions, and behaviors in persons who are at risk for such stigmatization in Jamaica. METHODS Data from a 2006 national survey on mental health were analyzed. Demographic variables, the presence or absence of mental illness in respondents and in their family members, and responses pertaining to behaviors and attitudes toward mentally ill persons were examined. Subsamples (respondents with mental illness, respondents with a family member with mental illness, respondents with neither) were compared using the chi-square test. RESULTS Respondents with family members with mental illness were less likely to demonstrate a number of different manifestations of stigmatization than others (P=0.009-0.019). Respondents with mental illness showed no difference in the demonstration of a number of different manifestations of stigmatization from other respondents (P=0.069-0.515). CONCLUSIONS The small number of mentally ill respondents resulted in low statistical power for demonstrating differences between that subgroup and other respondents. The significantly more positive attitudes and behavior of respondents with family members with mental illness suggest that some benefit may be gained by creating more opportunities for the general public to interact with persons with mental illness.

Double jeopardy: psychopathology of black mentally ill returned migrants to Jamaica

The psychopathology of 126 black Jamaican migrants who had spent an average of 12 years in North America and the United Kingdom and had subsequently returned to Jamaica, was established and compared to that of a matched control group of Jamaicans who had never migrated. There was a statistically significant difference in the pattern of diagnosis between the two groups (p < 0.0001), and although the existence of a past history of mental illness between the groups was not statistically significant (p < 0.1), the returned migrants had a significantly higher frequency of mental hospitalisation (p<0.0001) than the controls, with 94% of the previous hospitalisations of the returned migrants being for schizophrenic illnesses. Case studies are presented to illustrate the social stresses experienced by the returned migrant group in the countries to which they migrated and on the return to their home country, and thus to underscore the double jeopardy faced by these patients experiencing return migration.

Open Papers, Open Minds? Media Representations of Psychiatric De-institutionalization in Jamaica

Little research has been conducted on media representations of psychiatric de-institutionalization in low-income countries. We set out to examine whether the Jamaican media takes a positive or negative orientation to psychiatric de-institutionalization, and which arguments and rhetorical devices are employed to support the medias position. This was done by the collection, review, and analysis of all stories related to psychiatric de-institutionalization published over a 26-month period from 2003 to 2005 by Jamaicas principal broadsheet newspaper. All of the stories were positive in orientation. Articles alluded to the therapeutic and economic benefits of de-institutionalization. To allay public fears, articles gave prominence to the views of senior psychiatric experts, quoted supporting statistics and international trends, and translated relevant research findings into lay language. Our results are contrary to most studies in high-income countries indicating negative media portrayals of mental illness and the mentally ill.

From Explanitations and Madnificent Irations to de Culcha Clash: Popular Theatre as Psychotherapy

The use of culture as an instrument for education, consciousness-raising and demystification has been rediscovered and titled ‘people’s theatre’ or ‘popular theatre’ in recent years. The use of popular culture as a designated instrument for individual and group psychotherapy is a more recent phenomenon. The paper traces the development of an active popular theatre movement in Jamaica, intensified in the decade of the 1970s and building on the blueprint of Marcus Garvey and Edelweiss Park in Kingston in the early 1910s. The 1970s saw the popular theatre trend produce a wave of performing groups, such as The Bellevue Cultural Team, Gun Court, and Sistren Theatre Collective. The prototype for the cultural therapy process began as an eight-week workshop with the reggae band Third World, and produced the popular theatre piece Explanitations in 1978. Cultural therapy emerged as a large-group psychotherapy process in the Bellevue Mental Hospital soon after, and was called ‘sociodrama’. Between 1978 and 1981, the cultural therapy team at the Bellevue Mental Hospital produced annual pageants called Madnificent Irations, Visionated Penetrations, Madaptations, and Irations Explosion. The pageants told the story of the history of madness in a British postcolonial territory and the genesis of mental illness in specific patients of that hospital. The pageants challenged the participants and the audiences to re-evaluate preconceived notions and the stigma of ‘madness’. The cultural therapy process was applied as popular theatre in Grenada in 1980, producing Genesis of Ites; in Provident Hospital, Baltimore, USA, in 1981, producing Cooling the Fires of Hell; and in Belize in 1982, producing Mongrel Juice. In Jamaica, the cultural therapy trend culminated in the novel fusion of dub music and the operetta in 1992, resulting in the production of Krossroads – de Culcha Clash.The psychotherapeutic outcome of the process is outlined and discussed.

Understanding patients in multicultural settings: a personal reflection on ethnicity and culture in clinical practice

Objective. To identify and discourse on the complexities of ethnicity and culture, their role in the social and psychological functioning of patients and their potential impact on clinical assessment and treatment of these patients in diverse cultural contexts. Design. Description of aspects of the cultural competence required by clinicians in mental health service provisions in therapeutic interactions involving the therapist and patient and also in the encounter between practitioners. Results. The four-decade clinical experience of the author, an African Jamaican psychiatrist, encompasses clinical experience in the Caribbean, North America, Europe and New Zealand. From this wealth of multicultural clinical practice the author uses personal examples of four experiences with patients and professionals of African Caribbean, British and Maori ethnicities to discuss issues of ethnicity, ethnic identity and stereotyping, culture, cultural competency and alterity in the exchanges between the therapist and patient, and between therapists and the difficulties encountered in effective assessment and treatment of patients in multicultural settings. The author highlights the importance of historical experience in the psychological constitution of patients, which is the basis of a novel analytic model called psychohistoriography. This insight-oriented individual or group-focused intervention was created with the intention of attempting to heal the wounds of history; an aim that is absent from existing psychoanalytic treatment modalities. Conclusion. Psychohistoriography may be a viable therapeutic option in the negotiation of cross-cultural clinical interactions.

Psychopathology of white mentally ill immigrants to Jamaica.

Object: To test the hypothesis that white immigrants to a predominantly black country have a different pattern of psychopathology from the native population.Method: The psychopathology (DSM IIIR) of white immigrants to Jamaica seen in the authors private practice between 1979 and 1990 was compared with the psychopathology of a control sample of native Jamaicans matched with the immigrant sample for age, sex, and social class.Results: There was no statistical difference in the major diagnoses mood disoder (35%), anxiety states (27%), and schizophrenia (20%) between the immigrant and control groups. White immigrants to this black country did not develop schizophrenia at higher rates than the native born. White mentally ill immigrants to Jamaica move into social class positions at a significantly higher level (p<0.005) than those of their parents with whom they grew up in their home country. This was significantly different (p<0.005) from their Jamaican controls. Two case studies are presented to illustrate these findings.Conclusions: The political/economic situation which exists in black postcolonial countries like Jamaica provides a protective social environment for white immigrants, which buffers them from the etiological conditions that engender schizophrenia in immigrants to other countries with predominantly white populations.

Fostering Resilience in Children at Risk through a Cultural Therapy Intervention in Kingston, Jamaica

This report explores an initiative in Kingston, Jamaica to foster resilience in children in an inner-city community plagued by violence and other social problems. This initiative was undertaken by CARIMENSA, the Caribbean Institute for Mental Health and Substance Abuse.